Single-level selective dorsal rhizotomy for spastic cerebral palsy

Graham, David; Aquilina, Kristian; Cawker, Stephanie; Paget, Simon P; Wimalasundera, Neil

doi:10.21037/jss.2016.08.08

Cited by 24 publications

(17 citation statements)

References 44 publications

(66 reference statements)

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“…These results were comparable to those SDR managed via the traditional way. Not surprisingly, like what earlier studies concluded [ 1 , 14 , 15 , 17 – 19 ], our data showed as well that mild cases improved much better than those severe ones. Cases with their pre-op GMFCS level of II and III had more chance to have their level upgrade than those with IV and V (24/57 vs. 3/24) after the rehabilitation therapy.…”

Section: Discussionsupporting

confidence: 92%

“…To reduce muscle tone mainly in particular spastic muscles of lower limbs in spastic cerebral palsy (CP) children via single-level approach selective dorsal rhizotomy (SL-SDR) using a universally applicable rhizotomy protocol still remains challenging [ 1 ]. In the current study, we investigated whether our modified rhizotomy protocol-guided SL-SDR which could effectively decrease muscle tone of those particular spastic muscles in hemiplegic cases could be applied as well in spastic diplegic and quadriplegic pediatric CP cases.…”

Section: Introductionmentioning

confidence: 99%

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Whether the newly modified rhizotomy protocol is applicable to guide single-level approach SDR to treat spastic quadriplegia and diplegia in pediatric patients with cerebral palsy?

Zhan

Jiang

et al. 2019

Childs Nerv Syst

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Purpose Our aim was to test whether the newly modified rhizotomy protocol which could be effectively used to guide single-level approach selective dorsal rhizotomy (SL-SDR) to treat spastic hemiplegic cases by mainly releasing those spastic muscles (target muscles) marked pre-operatively in their lower limbs was still applicable in spastic quadriplegic or diplegic cerebral palsy (CP) cases in pediatric population. Methods In the current study, we retrospectively conducted a cohort review of cases younger than 14 years of age diagnosed with spastic quadriplegic or diplegic CP who undergone our modified protocol-guided SL-SDR in the Department of Neurosurgery, Children’s Hospital of Shanghai since July 2016 to November 2017 with at least 12 months post-op intensive rehabilitation program (pre-op GMFCS level-based). Clinical data including demographics, intra-operative EMG responses interpretation, and relevant assessment of included cases were taken from the database. Inclusion and exclusion criteria were set for the selection of patients in the current study. Muscle tone (modified Ashworth scale) and strength of those spastic muscles (muscle strength grading scale), range of motion (ROM) of those joints involved, the level of Gross Motor Function Classification System (GMFCS), and Gross Motor Function Measure 66 items (GMFM-66) score of those cases were our focus. Results A total of 86 eligible cases were included in our study (62 boys). Among these patients, 61.6% were quadriplegic. Pre-operatively, almost 2/3 of our cases were with GMFCS levels II and III. Mean age at the time of surgery in these cases was 6.2 (3.5–12) years. Pre-op assessment marked 582 target muscles in these patients. Numbers of nerve rootlets tested during SDR procedure were between 52 and 84 across our cases, with a mean of 66.5 ± 6.7/case. Among those tested (5721 in 86 cases), 47.9% (2740) were identified as lower limb-related sensory rootlets. Our protocol successfully differentiated sensory rootlets which were considered to be associated with spasticity of target muscles across all our 86 cases (ranged from 3 to 21). Based on our protocol, 871 dorsal nerve rootlets were sectioned 50%, and 78 were cut 75%. Muscle tone of those target muscles reduced significantly right after SL-SDR procedure (3 weeks post- vs. pre-op, 1.7 ± 0.5 vs. 2.6 ± 0.7). After an intensive rehabilitation program for 19.9 ± 6.0 months, muscle tone continued to decrease to 1.4 ± 0.5. With the reduction of muscle tone, strength of those target muscles in our cases improved dramatically with statistical significance achieved (3.9 ± 1.0 at the time of last follow-up vs. 3.3 ± 0.8 pre-op), and as well as ROM. Increase in GMFCS level and GMFM-66 score was observed at the time of last follow-up with a mean of 0.4 ± 0.6 and 6.1 ± 3.2, respectively, when compared with that at pre-op. In 81 cases with their pre-op GMFCS levels II to V, 27 (33.3%) presented improvement with regard to GMFCS level upgrade, among which 4 (4.9%) even upgraded over 2 levels. Better results with regard to upgrading in level of GMFCS were observed in cases with pre-op levels II and III when compared with those with levels IV and V (24/57 vs. 3/24). Upgrading percentage in cases younger than 6 years at surgery was significantly greater than in those older (23/56 vs. 4/25). Cases with their pre-op GMFM-66 score ≥ 50 had greater score increase of GMFM-66 when compared with those less (7.1 ± 3.4 vs. 5.1 ± 2.8). In the meanwhile, better score improvement was revealed in cases when SDR performed at younger age (6.9 ± 3.3 in case ≤ 6 years vs. 4.7 ± 2.7 in case > 6 years). No permanent surgery-related complications were recorded in the current study. Conclusion SL-SDR when guided by our newly modified rhizotomy protocol was still feasible to treat pediatric CP cases with spastic quadriplegia and diplegia. Cases in this condition could benefit from such a procedure when followed by our intensive rehabilitation program with regard to their motor function.

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Section: Discussionsupporting

confidence: 92%

Section: Introductionmentioning

confidence: 99%

Whether the newly modified rhizotomy protocol is applicable to guide single-level approach SDR to treat spastic quadriplegia and diplegia in pediatric patients with cerebral palsy?

Zhan

Jiang

et al. 2019

Childs Nerv Syst

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“…Short- (18 months) and long-term (13 years) results at our institution based on these criteria have been published previously. 21 , 22 Our criteria here share similar items to those published by other institutions, such as Oswestry 23 and Great Ormond Street 24 ( Appendix A ). Exceptions include our use of 3DGA and standardized assessment tools of spasticity, such as the Ashworth scale 25 and the Hypertonia Assessment Tool (HAT).…”

Section: Patient Selection For Sdrmentioning

confidence: 99%

“…Extensive rehabilitation is required and is part of the SDR protocol in most institutions performing this procedure. 24 , 38 , 55 , 61 Physiatrists and physical therapists should be part of the team giving input into the patient selection process as well as communicating to parents regarding postoperative expectations and rehabilitation plans. At our institution, rehabilitation following SDR differs significantly to rehabilitation following SEMLS.…”

Section: Sdr Within a Multi-disciplinary Multi-modal Approachmentioning

confidence: 99%

Selective dorsal rhizotomy in ambulant children with cerebral palsy

Wang

Munger

Chen

et al. 2018

Journal of Children's Orthopaedics

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Abstract:BackgroundSelective dorsal rhizotomy (SDR) is a surgical procedure for treating spasticity in ambulant children with cerebral palsy (CP). However, controversies remain regarding indications, techniques and outcomes.Current evidence summaryBecause SDR is an irreversible procedure, careful patient selection, a multi-disciplinary approach in assessment and management and division of the appropriate proportion of dorsal rootlets are felt to be paramount for maximizing safety. Reliable evidence exists that SDR consistently reduces spasticity, in a predictable manner and to a substantial degree. However, functional improvements are small in the short-term with long-term benefits difficult to assess.Future outlookThere is a need for high-quality studies utilizing long-term functional outcomes and well-matched control groups. Collaborative, multicentre efforts are required to further define the role of SDR as part of the management paradigm in maximizing physical function in spastic CP.

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“…The available treatments provide some relief; SDR provides spasticity reduction and provides modest improvement or maintenance of function [9]. The strength of the evidence supporting the treatments is weak however, guidelines for use exist [10], but no cost‐effectiveness studies have been conducted [11].…”

Section: Spasticity and Its Treatmentmentioning

confidence: 99%

Spinal cord stimulation for the relief of spasticity from cerebral palsy

Parker

Dietz

2020

Healthcare Technology Letters

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Cerebral palsy (CP) is the most common form of childhood disability, and spasticity is the most common motor-manifestation. Thankfully, there has been a significant reduction in the percentage of children born with CP in recent years, but nonetheless, those afflicted children can face life long devastating disabilities. Spinal cord stimulation (SCS), an implanted device used to treat chronic neuropathic pain, has been used to treat children with spasticity. In some cases, it has been shown to produce a remarkable improvement but despite this, the technique is not commonly used. There are a number of case series, and retrospective reports of outcomes with the most successful demonstrating a nearly 1.5point reduction in Ashworth scale, the least successful demonstrating no significant improvements. Here, the authors examine the clinical reports and propose a mechanism of action based on the current understanding of SCS. Technology development in SCS for pain management has progressed significantly since the early clinical experience with CP and some of the new technology may be able to better exploit the putative mechanism. The advent of compound action potential recording and closed-loop control could lead to new insights into the electrophysiology and how to better tune these devices to provide more substantial relief from symptoms.

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Single-level selective dorsal rhizotomy for spastic cerebral palsy

Cited by 24 publications

References 44 publications

Whether the newly modified rhizotomy protocol is applicable to guide single-level approach SDR to treat spastic quadriplegia and diplegia in pediatric patients with cerebral palsy?

Whether the newly modified rhizotomy protocol is applicable to guide single-level approach SDR to treat spastic quadriplegia and diplegia in pediatric patients with cerebral palsy?

Selective dorsal rhizotomy in ambulant children with cerebral palsy

Spinal cord stimulation for the relief of spasticity from cerebral palsy

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